Safe and Effective Care

1. The physcian's order reads: "100cc D5W with80 mEQ of KCL to infuse in 1/2 hour." Your first action will be to:
a. assess urine output.
b. ensure the patency of the IV line.
c. request an order for Lidocaine to be added to the IV
d. check the accuracy of the order.
Potassium chloride must be diluted and administered at a rate no faster than 20mEq/hr. Options #1 and #2 are correct after
the order has been corrected. Option #3, Lidocaine, should not be added to this IV.

2. A client diagnosed with acquired immunodeficiency syndrome (AIDS) is admitted to a medical unit for treatment of
dehydration secondary to diarrhea. Which nursing action is necessary to prevent nosocomial infection?
a. Provide room with an intercom.
b. Use sterile sheet whenever possible.
c. Use chux to prevent skin irritation.
d. Use a doughnut foam ring on coccyx.
Diarrhea predisposes AIDS clients to decubiti which can lead to significant infection. Therefore, sterile sheets are indicated to
reduce risk. Options #1, #3, and #4 do not decrease the risk of infection.

3. The nurse is changing a dressing on an infected abdominal wound with Penrose drains and a large amount of purulent
drainage. What is the best way to perform this procedure?
a. Obtain clean gloves and dressings, remove the soiled dressing, and use another pair of clean gloves to dress the
wound.
b. Use clean gloves to remove the soiled dressings, change to sterile gloves and use sterile dressings to cover the
wound.
c. Use the sterile gloves to remove the dressing, obtain clean gloves and sterile dressing to reapply to the wound.
d. Initiate protective isolation, utilize only sterile gloves when removing the dressing, and reapply using sterile
technique.
Sterile gloves and dressings are used in the application of dressings to wounds. Option #4 is incorrect because protective
isolation is not appropriate for this client. Sterile gloves are not necessary for removing the soiled dressings.

4. A client with a history of cardiac disease is admitted to the hospital with a diagnosis of congestive heart failure. The doctor's
orders are: continue all previous medications which include digoxin (Lanoxin) .25 mg po each AM, and propranolol (Inderal)
20 mg po tid; oxygen at 4L/minute via nasal cannula, establish an IV and give furosemide (Lasix) 40 mg IV now, bathroom
privileges, full liquid diet. Which part of the order would be apriority for the nurse to discuss with the doctor?
a. Digoxin (Lanoxin) 0.25 mg PO in AM.
b. Level of oxygen concentration.
c. Propranolol (Inderal) 20 mg tid.
d. How fast should the IV infuse.
Inderal is contraindicated in clients with CHF. It is possible the doctor overlooked this in reordering all of the client's previous
medications. The oxygen, and digoxin are appropriate. There is no specific order regarding the rate of infusion or any fluids to
be infused. Since the client is on po fluids, this is probably a heparin/saline lock. This order should be clarified. However,
Option #3 is a priority.

5. Which assignment is the most appropriate for a client in the burn unit who has a cytomegalovirus (CMV) infection? A nurse
who
a. has an upper respiratory infection. c. is CMV negative.
b. is eight weeks pregnant. d. has thirty years experience.
This option is most appropriate due to a decreased risk of being infected. Option #1 is incorrect because those with a
cytomegalovi-rus positive titer are often immunosuppressed clients who should be protected from other pathogens. Option #2
is incorrect because CMV is fetotoxic, and those who are pregnant should not care for CMV+ clients. Option #3 is incorrect
because those with no protective titer are an increased risk for developing the disease if exposed.

6. Which measure should a nurse take to prevent the spread of active pulmonary tuberculosis?
a. Restrict visitors to immediate family only.
b. Wear gown and gloves at all times.
c. Wear mask and gloves when in direct contact.
d. Dispose of waste articles more frequently.
Respiratory precautions call for masks and gloves to be worn to prevent the spread of the causative organism. Options #1, #2,
and #4 are not essential in respiratory isolation.

7. A postoperative nursing goal is to maintain ad equate nutrition and elimination. Which nursing order would be
appropriate?
a. Assess for peristalsis; do not begin PO fluids until bowel sounds are present.
b. Maintain client NPO until passing flatus; maintain normal urine output.
c. Catheterize client; place retention catheter if unable to void 4 hours after surgery.
d. Anticipate abdominal distention; place nasogastric tube PRN every 4 hours.
To prevent abdominal distention, PO fluids should not be started until bowel sounds are present or there is other evidence of
active peristalsis. Option #2 is incorrect because the client does not have to be NPO until bowel sounds are established. Option
#3 is incorrect because catheterization should be avoided unless absolutely necessary. Option #4 is incorrect because
nasogastric tubes are not placed on a PRN bases.

8. A 54-year-old client with tertiary syphilis is admitted to a nursing unit exhibiting signs of marked dementia and
disorientation. Which nursing action should be done initially?
a. Place the nurse call bell within reach
b. Frequently observe client behavior
c. Apply a vest-type restraint.
d. Provide an around-the-clock sitter.
Placing the client on frequent observation status would be the first action to ensure the client's safety. Option #1 is incorrect
because it should not be assumed that the client will be able to use the call light appropriately. Option #3 should never be the
first option used by a professional nurse. Current standards require not only a physician's order, but a time limit, exact type of
restraint to be used, and the specific rationale for restraint. Option #4 may be suggested to the family at a later time.

9. A client with a necrotizing spider bite is to perform dressing changes at home. Which statement made by the client
indicates a correct understanding of aseptic technique?
a. "I need to buy sterile gloves to redress this wound."
b. "I should wash my hands before redressing my wound."
c. "I should not expose the wound to air at all."
d. "I should use an over-the-counter antimicrobial ointment."
The hallmark of asepsis is hand-washing. Option #1 is incorrect because the question addresses medical aseptic technique, not
sterile procedure. Option #3 is not necessary. Option #4 is incorrect because the client should use only prescribed medications
on the wound.

10. Before administering pin site care to a client in skeletal traction, the nurse should check:
a. correct alignment
b. appearance of pin sites.
c. tightness of screws.
d. client vital signs.
Prior to pin site care, each pin site should be examined carefully for drainage or redness since they represent direct access to
bone. Options #1, #3, and #4 are unnecessary with respect to site care.

11. Which observation indicates the need for a nurse to stay with a client admitted to the emergency room following a car
wreck?
a. Disorientation and irregular vital signs.
b. Irregular vital signs and hostility.
c. Rapid respirations and agitation.
d. Elevated vital signs and apprehension.
A disoriented client with irregular vital signs represents a grave safety risk. Options #2, #3, and #4 may increase the need for
nursing interaction/assessment and are secondary to Option #1.

12. In planning the debridment of a burn, a nurse would give priority to which action?
a. Assemble all necessary supplies and medications
b. Organize time for dressing change and provide emotional support.
c. Prepare the client and family for the pain the client will experience during and after the procedure.
d. Limit visitation prior to procedure to reduce client stress.
Prior planning for burn wound treatment should include organizing and planning for the mechanics of the procedure as well
as the emotional support necessary for the client. Options #1, #3, and #4 may be appropriate but do not take priority over
Option #2.

13. Prior to performing a physical assessment on a client who speaks little English, which nursing action is the most
appropriate?
a. Attempt to prepare client with hand signals.
b. Show the client pictures of the physical exam process.
c. Contact an employee who speaks client's primary language to translate.
d. Speak slowly as you explain what you are doing.
Staff who speak other languages are usually noted by nursing administration for such instances where a translator is the
best option. Options #1, #2, and #4 would be less effective.

14. During the insertion of a central venous pressure monitor, the tip of the monitor device brushes the underside of the
sterile field. Which nursing action is most appropriate?
a. Wipe the tip with alcohol before connecting to system
b. Notify the physician of the occurrence so an antibiotic can be given.
c. Back-flush catheter for several seconds before connecting
d. Obtain a new monitor device, and prepare for a second attempt.
Contamination of equipment mandates new equipment be employed. Options #1 and #3 are not adequate—the catheter is
still contaminated. Option #2 may be appropriate later, but obtaining a new monitoring device is a priority.

15. Which postoperative nursing goal will assist in preventing deep vein thrombosis?
a. Decrease the flow of the venous blood.
b. Increase the coagulation of the blood.
c. Increase the flow of the venous blood.
 d. Improve the oxygen capacity of the blood.
It is important to prevent venous Stasis by increasing the flow of venous return. Options # 1 and #2 will increase the risk
associated with DVT. Option #4 will not affect the course of deep vein thrombosis.

16. Ipecac syrup has been given to a client after accidental ingestion of a poisonous plant. Which nursing observation is
most important to report to the next shift?
a. No vomiting has occurred after dose was given.
b. An antiemetic has been ordered and given.
c. A slight increase in temperature has been noted.
d. The client will be NPO until the next day.
No response to Ipecac after the dose should be reported to next shift and the physician for further action. Options #2 and
#3 are nones-sential. Option #4 is not a high priority

17. A client with chronic lung disease is admitted to the acute pulmonary unit with: respiratory rate of 50; pulse of 140 and
irregular; skin pale and cool to touch; client confused as to place and time. Orders are: oxygen per nasal cannula at
4L/minute, bedrest, soft diet and pulmonary function tests in the AM. What is the best sequence of nursing activities?
a. Place in semi-Fowler's position, begin the oxygen, have someone stay with the client, then notify the doctor
regarding the current status of the client.
b. Begin the oxygen, call the nursing supervisor, keep the bed flat to maintain blood pressure, and stimulate
client to take deep breaths
c. Call the nursing supervisor, discuss with the family if the client has experienced this problem before, offer the
client sips of clear liquids
d. Advise respiratory therapy of the client's problem, place the client in semi-Fowler's position, and begin the
oxygen.
The doctor's orders do not address the seriousness of the client's condition. The doctor should be notified immediately.
However, the client should not be left alone. Options #2, #3, and #4 do not address the seriousness of the client's
immediate needs.

18. The nurse arrives for the day shift and receives her assignments around 7:30 a.m. The assignment includes:
• a man with a diagnosis of rule-out an MI. He is on a monitor and having 4-6 premature beats per hour.
• an elderly lady who is confused and has constant urinary dribbling.
• a pneumonia client with increasing confusion and a temperature of 104° at 6:30 a.m.
• a diabetic client who experienced a restless night and 7:00 a.m. blood sugar was 170mg%.
Which client is a priority and how should the nurse plan her care?
a. The pneumonia client has priority; his condition should be assessed immediately.
b. The elderly lady is probably wet and uncomfortable and should be taken care of first. Then obtain a stat blood
glucose to determine the diabetic client's current blood sugar level.
c. The cardiac client should be assessed immediately as the monitor indicates cardiac irritability. Then the
temperature on the pneumonia client should be reassessed.
d. The diabetic client should be seen immediately to assess for evidence of hyperglycemia. Then the pneumonia
client should be assessed for patency of airway.
The sickest client is the pneumonia client, and his needs should be addressed first. This client has an increased temperature,
which may indicate his pneumonia is getting worse; and his confusion may be indicative of hypoxia. His status should be
evaluated immediately. Premature beats of 4—6 per hour are benign and not unusual for a cardiac client. The elderly lady
may be uncomfortable, but the respiratory status of the pneumonia client is priority. A blood sugar of 170 mg% is abnormally
high and should be addressed. However, the respiratory status of the pneumonia client is the highest priority.

19. Which nursing observation is most important to report to the physician on a client with a second-degree thermal injury to
right arm?
a. Pain around the periphery of injury.
b. Gastric pH less than 6.0.
c. Increased edema of right arm.
d. An elevated hematocrit.
A decrease in gastric pH could indicate the hypersecretion of hydrogen ions—a predisposing factor to stress ulcer formation.
Options #1, #3, and #4 are expected findings in burn wound resolution.

20. In planning health teaching about the Recombivax immunization against Hepatitis, it is most important to include:
a. recombivax is given at specific intervals in a series of three.
b. the immunization can only be given IM.
c. allergic reactions are possible since human plasma is used.
d. recombivax has been associated with AIDS
The necessity of completing the series of three injections is an important factor to include in education concerning immuniza-
tion with Recombivax. Options #2, #3, and #4 contain false information.

21. A postoperative client is receiving bupivacaine hydrochloride (Marcaine) for pain through an epidural catheter. Which
response should the nurse recognize as desirable for this pain management technique?
a. Decreased respirations.
b. Somnolence.
c. Decreased restlessness.
d. Decreased blood pressure.
A decrease in physiological shortness of breath and restlessness is a desired outcome criteria of pain management. Options #1,
#2, and #4 are undesired responses.

22. At 5:00 p.m., the nurse on the evening shift opens the nurses' notes and discovers that the last entry was at 9:00 a.m. The
day nurse did not complete the charting and did not sign the nurses' notes. The best action for the evening nurse is to:
a. leave a note on the front of the chart for the day nurse to make a late entry and begin charting on the line below
the last entry on the nurse's notes.
b. leave enough space for the day nurse to complete her charting when she comes in the next morning.
c. not chart anything until the day nurse returns to complete the charting for her care delivered that morning.
d. call the day nurse and ask her about the care she gave that morning so the evening nurse can complete the chart.
The best way to handle the situation is to begin charting on the next line and have the day nurse make a late entry for the
omitted information. Options #2, #3, and #4 would be illegal.

23. The most important information for a nurse to obtain about abdominal drainage from a client with postoperative
abdominal abscess
a. Amount
b. character.
c. consistency.
d. amount of suction on system.
The character of the drainage, purulent or otherwise, is a major priority to note and report. Options #1 and #3 are lower
priority. Option #4 is unnecessary.

24. A client has returned from surgery with a fine reddened rash noted around the area where Betadine prep had been applied
prior to surgery. Nursing documentation in the chart should include:
a. the time and circumstances in which the rash was noted.
b. explanation to client and family the reason for rash.
c. notation on an allergy list and notification of the physician.
d. application of corticosteroid cream to decrease inflammation.
Any suspected reaction to drugs should be reported to the physician and noted on the list of possible allergies. Option #1 would
be noted, but is not as high a priority as Option #3. Options #2 and #4 are inappropriate.

25. The nurse is changing the dressing on a client with a large abdominal wound. There are two Penrose drains in place. What is
the priority information for the nurse to include when recording this procedure?
a. Condition of the surrounding tissue, time necessary to change the dressing, the type of dressing used.
b. Client's tolerance of the procedure, time the dressing was changed, amount of wound drainage.
c. Client's response to the dressing change, status of Penrose drains, type of drainage from Penrose drains.
d. Time dressing was changed, description of the wound, color and amount of drainage from Penrose drains.
The information in Option #4 best describes the essential information that should be charted after a dressing change for a
wound of this type. Options #1, #2 and #3 contain important information. However, the information in #4 is more important.

26. A client is admitted to the emergency room after a motor vehicle accident. He does not remember the accident. He is
awake, oriented to person, but does not know what city he is in. He is confused regarding the day and month. Pupils are
equal in size and equally reactive to direct light reflex. He is complaining of a severe headache and is becoming restless. The
priority of care for this client is to:
a. continue to stimulate the client to keep.him oriented to his surroundings.
b. restrain the client to prevent him from injuring himself
c. perform bedside neuro checks every fifteen minutes.
d. administer meperidine hydrochloride (Demerol) for pain control and to decrease restlessness.
The client may be developing increased intracranial pressure and should be monitored closely. Option #4, Demerol, is not
given for pain control. It will mask the signs of increased intracranial pressure. Option #2, restraining, is not necessary at this
time, and pulling against restraints will increase intracranial pressure. Option #1, continued stimulation, does not provide any
benefit for this client.

27. Which is an appropriate and cost-effective measure for a charge nurse to implement during a low census day shift?
a. Keep all staff because the patient census may increase.
b. Call the hospital supervisor, and let her make the decision.
c. Dismiss excess staff, but tell them to stay by the phone. They may be needed later.
d. Dismiss excess staff home, and tell them to take the day off with pay.
Excess staff may be floated to another unit that is in need of personnel. The house supervisor would have that information,
thus making a cost effective decision. Options #1 and #4 are not cost effective. Option #3 violates the labor laws unless the
nurse on call is being paid a wage to "stay by the phone

28. Which would be the most appropriate to assign to the LPN?

a. A client who is being discharged and needs new diabetic teaching
b. A client who is a new admission with chest pain.
c. A client who is receiving chemotherapy.
d. A client who has the diagnosis of Myasthenia Gravis.
Option #1 is incorrect because it requires initial teaching. The LPN can reinforce teaching, but it is currently not in the scope
of practice to do the initial teaching. Option #2 would require initial assessment. LPNs can do ongoing assessment, but it is not
in the scope of practice to complete the initial assessment. Option #3 would require IV management and specialized assessment
skills so it is not a priority to Option #4.

29. While assessing the incision of a 2-day postoperative client, a shiny pink open area is noted with underlying visible bowel.
Which action should the nurse take first?
a. Cover gaping area with sterile gauze soaked in normal saline.
b. Reapply sterile dressing after cleaning with peroxide.
c. Pack opened area with sterile 3/4 inch gauze soaked in normal saline
d. Apply Neosporin ointment and cover with Tegaderm dressing.
Evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline followed by notification of
the physician. Options #2, #3, and #4 are not correct responses to this complication.

30. Which intervention indicates the nurse has an understanding of safe medication administration for the pediatric client?
a. Validate the order with the chart after the medication has been administered.
b. Verify client identify by looking at the arm bracelet prior to administering the medication.
c. Contact the pharmacist for clarification of all the possible adverse reactions which may occur prior to giving any
medication.
d. Administer the medication in the child's formula to prevent an increase in anxiety.
It is imperative to verify the identity prior to implementing any procedure with any client. Medication errors often result from
inappropriate identification. Option #1 is incorrect because it should be validated prior to administering it. Option #3 is
unnecessary. Nurses must be aware of possible side effects as well as adverse reactions; however, it is not necessary to address
with the pharmacist prior to every drug. Option #4 is inappropriate since the child may refuse the bottle. It should be given
with a medication syringe or dropper.

31. Which nursing implication is important regarding spinal anesthesia?

a. The client should be adequately hydrated in order to prevent hypotension after anesthesia is established.
b. The client must be NPO at least 12 hours prior to the initiation of the anesthesia to decrease the risk of aspiration.
c. Assess the client for any allergies to betadine or iodine preparations.
d. Determine the specific gravity of the urine and prepare the client for a central line.
It is important that the client be well hydrated to prevent hypotensive problems after the spinal anesthesia is initiated. Option
#2 is unnecessary. Option #3 is not necessary as iodine dyes are usually not used. Option #4 is irrelevant to the procedure.

32. A 6-month-old infant has had all required immunizations. This would include:
a. two doses of DPT and two doses of TOPV
b. MMR.
c. TB skin test and one dose of DPT.
d. Small Pox vaccine and MMR.
The first dose of the DPT and TOPV may be given at approximately six weeks to two months, and the second is given at four
months. Option #2 is given at fifteen months. Option #3 is incorrect because the TB skin test is given at about twelve months.
Option #4 is incorrect because the small pox vaccine is no longer recommended, and the MMR is given at about fifteen months.

33. Which symptom would cause a nurse to be concerned about postinfusion phlebitis in a client who has been on an IVPB
antibiotic mixed in D5W every 8 hours for four days?
a. Tenderness at the IV site
b. Increased swelling at the insertion site
c. Reddened area or red streaks at the site.
d. Leaking of fluid around the IV catheter.
Postinfusion phlebitis is characterized by inflammation and reddened areas around the site of needle puncture and up the
length of the vein. Option #1 is fairly common. Option #2 may be indicative of infiltration. Option #4 is not indicative of
phlebitis.

34. After taking the vital signs of a client returning from abdominal exploratory surgery, which action should be taken next?
a. Position the client on her left side supported with pillows
b. Check the chart and determine the status of fluid balance from surgery.
c. Check the client's abdominal dressing for any evidence of bleeding.
d. Monitor the incision and pulmonary status for presence of infection.
The dressing should be checked on admission to the room and frequently for several hours. Options #1 and #2 are not priority
at this time. Option #4 is inappropriate as it is too soon for infection to occur secondary to surgery.

35. To evaluate the adverse reactions from antibiotic therapy in a client with a postoperative infection and receiving
ceftriaxone sodium (Rocephin) IVPB every day, the nurse should monitor:
a. surface of the tongue.
b. hemoglobin and hematocrit.
c. skin surfaces in skin folds.
d. changes in urine characteristics.
Long-term use of Rocephin can cause overgrowth of organisms such as Candida albicans; therefore, monitoring of the tongue
and oral cavity is recommended. Options #2, #3, and #4 do not reflect a problem with this medication.

36. When irrigating a draining wound with a sterile saline solution, which sequence would be most appropriate for the nurse to
follow?
a. Pour solution, wash hands, and remove soiled dressing.
 b. Wash hands, prepare sterile field, remove soiled dressing.
c. Prepare sterile field, put on sterile gloves, and remove soiled dressing.
d. Remove soiled dressing, flush wound, wash hands.
Hand-washing should be done prior to beginning any procedure—especially irrigating a wound. Options #1, #3, and #4 are in
the incorrect sequence.

37. To maintain client safety, which equipment should be readily available when inserting an Ewall tube?
a. Suction equipment.
b. Blood pressure cuff.
c. Levine tube.
d. Emesis basin.
The Ewall tube is a large orogastric tube designed for rapid lavage. Insertion often causes gagging and vomiting such that
suction equipment must be immediately available to reduce risky aspiration. Options #2, #3, and #4 are not as high priority.

38. Which would have the highest priority when caring for a terminally ill client during the final stage of dying?
a. Encourage family to discuss legal matters with an attorney.
b. Provide privacy for the client and his family to spend time together.
c. Keep client sedate.
d. Encourage family to limit visiting hours so they can rest.
A priority is to provide privacy. Options #1 and #3 are inappropriate at this time. Option #4 is partially correct about rest, but
incorrect regarding the limiting of visiting hours.

39. The charge nurse demonstrates an understanding of appropriate delegation when she makes which client assignment to
the LPN?
a. A psychotic client.
b. A client receiving chemotherapy.
c. A client in Buck's traction.
d. A client receiving a blood transfusion.
This client is the lowest acuity out of the group and requires the least specialized care. The scope of practice for the LPN would
allow her to care for this client. Options #1, #2, and #4 require care from the RN which is out of the LPN's scope of practice.

40. Which statement indicates the client has an appropriate understanding of how to adequately use the albuterol and Vanceril
inhalers?
a. "I will wait 10 minutes between the 2 medications."
b. "It doesn't matter how long I wait or the order in which they are taken."
c. "I will wait 2-3 minutes between taking the Vanceril and the Albuterol inhalers."
d. "I will wait 1-3 minutes between taking the Albuterol and Vanceril inhalers."
The bronchodilator should be taken prior to the steroid inhaler and a period of 1-3 minutes should be between the 2
medications. Options #1, #2, and #3 are incorrect.

41. To protect a post heart transplant client from potential sources of infection, the nurse would:
a. keep client in total isolation.
b. limit participation in unit activities.
c. adhere to and monitor strict hand-washing techniques.
d. monitor vital signs, especially temperature, every 2 hours.
One of the most important nursing strategies with a client who is immunosuppressed is adherence to, and monitoring hand-
washing of, others to prevent transmission of sources of infection. Option #1 is not necessary although a private room might be
helpful. Option #2 would allow the client to further withdraw and limits their opportunities for corrective milieu experiences.
Option #4 is more often than necessary unless there is a temperature elevation.

42. Which instruction is correct regarding the collection of a specimen from a 4-year-old suspected of having pinworms?
a. Collect the specimen 30 minutes after the child falls asleep at night.
b. Save a portion of the child's first stool of the day, and take it to the physician's office immediately.
c. Collect the specimen in the early morning with a piece of scotch tape touched to the child's anus.
d. Feed the child a high fat meal; then save the first stool following the meal.
Pinworms crawl outside the anus early in the morning to lay their eggs. This specimen should be collected early in the morning
before the child awakens. Option #1 is not the optimum time for collecting the eggs and may result in a false negative test.
Option #2 is incorrect because pinworms are rarely found in the stool. Option #4 is incorrect protocol for this test.

43. Which nursing action has the highest priority for a teenager admitted with burns to 50% of the body?
a. Counseling regarding problems of body image.
b. Maintain respiratory isolation.
c. Maintain aseptic technique during procedures.
d. Encourage peers to visit on a regular basis.
Safety is a priority for the client who is at high risk for infection. Option #1 may be necessary at some point, but safety issues
come first. Option #2 is incorrect because the appropriate isolation technique should be protective—not respiratory—isolation.
Option #4 is important for an adolescent but is not a priority over safety.

44. Which observation indicates a mother needs further teaching regarding protecting the newborn from infection?
a. Applies alcohol to the umbilical cord after a diaper change.
 b. Positions the diaper below the umbilicus.
c. Does not wash her hands prior to handling the newborn.
d. Applies a sterile gauze with petroleum jelly to, the circumcision.
Proper hand-washing is a priority in preventing infection. Options #1, #2, and #4 are correct and do not indicate a need for
further teaching.

45. To promote safety in the care of a client receiving internal radiation therapy, the nurse would:
a. restrict visitors who may have an upper respiratory infection.
b. assign only male care givers to the client.
c. plan nursing activities to decrease nurse exposure.
d. wear a lead lined apron whenever delivering client care.
The principles for radiation safety are time, distance, and shielding. The nurse should decrease the time she spends at close
distance to the client. Option #1 is incorrect because all visitors must keep distance from the client. Option #2 is incorrect since
radiation is as harmful to males as to females. Option #4 is used when the nurse has to spend any length of time at close
distance with the client—not for routine care.

46. To promote safety in the environment of a client with a marked depression ofT cells, the nurse would:
a. keep a linen hamper immediately outside the room.
b. use sterile linens
c. provide masks for anyone entering the room
d. discard any standing water left in containers or equipment.
Water should not be allowed to stand in containers, such as respiratory or suction equipment, because this could act as a
culture medium. Option #1 is incorrect because the protocol for handling soiled articles is accomplished within universal
precautions guidelines using double biohazard bags. Option #2 is incorrect because sterile linens are used for burn and OR
clients. Option #3 is not protocol unless the client or visitor has an active pulmonary infection.

47. What should the client avoid prior to a skin biopsy?

a. Use of aspirin prior to procedure.
b. Deodorant soaps or lotion.
c. Exposure to sunlight prior to the biopsy.
d. Food or drink the morning of the biopsy.
Use of aspirin compounds can increase bleeding time and should not be taken prior to surgical procedures. Options #2, #3, and
#4 do not affect the accuracy of the biopsy.

48. Which nursing observation would indicate a major complication in a client who suffered a thermal injury two weeks ago?
a. Increased heart rate and elevated blood pressure.
b. Temperature of 100.6°F and decreased respiratory rate.
c. Increased heart rate and decreased respiratory rate.
d. Increased respiratory rate and decreased blood pressure.
Increased respiratory rate and decreased blood pressure may indicate bum wound sepsis—a life-threatening complication of
thermal injury. Options #1, #2, and #3 should be investigated further but alone do not represent significant compromise.

49. Which nursing action regarding intubation equipment/supplies is most appropriate following intubation of a
postoperative client who had a respiratory arrest?
a. Soak the intubation equipment in concentrated Betadine solution.
b. Place intubation blade in bag and arrange for gas sterilization.
c. Soak intubation blade in Cidex solution.
d. Wash with soap and water and allow to air dry.
Sterilization of equipment after exposure to body fluids of a client is protocol. Options #1, #3, and #4 are incorrect
because they do not provide sterility.

50. Which statement concerning the transmission of head lice would be most important for the nurse to teach?
a. Head lice occurs primarily in lower socioeconomic groups
b. Transmission is airborne through insect vectors.
c. Infestation is reduced in cold weather.
d. Transmission is most common where there are crowded living conditions.
Crowded living conditions where there is sharing of clothing and physical closeness increases the likelihood of
transmission. Option #1 is incorrect because head lice occur in all socioeconomic levels. Option #2 is incorrect because lice
are transmitted by close contact. Option #3 is incorrect because weather is not a deterrent—although more cases are seen
in the winter in some areas due to the sharing of hats.

51. What is the correct procedure for obtaining a throat culture from a client with pharyngitis?
a. Quickly rub a cotton swab over both tonsilar areas and posterior pharynx.
b. Obtain a sputum container for the client to use.
c. Following an irrigation with warm saline, the pharynx is swabbed.
d. Hyperextend the client's head and neck for the procedure.
The tonsilar and pharyngeal areas are quickly swabbed to avoid client discomfort. Option #2 is incorrect because this would
not reflect throat bacteria. Option #3 should not be done to obtain an adequate sample for culture. Option #4 is incorrect
because the client should hold his head upright—not hyperextended.

52. Which technique is correct when changing a large abdominal dressing on an incision with a Penrose drain?
 a. Remove dressing layers one at a time.
b. Clean the wound with Betadine solution and hydrogen peroxide.
c. Clean drainage area first.
d. If the dressing adheres to the wound, pull gently and firmly.
To avoid dislodging the drain, remove the dressing layers one at a time. Option #2 is incorrect because the wound should not
be cleaned with both a Betadine solution and hydrogen peroxide. Option #3 is incorrect because the wound is cleaned from the
center outward to the edges and from top to bottom. Option #4 could tear the skin and dislodge the drain.

53. Which observation should the nurse make on initial assessment of a client with multiple facial fractures?
a. Vital signs.
b. Patent airway.
c. Breath sounds
d. Skin color.
Airway is the crucial first step to trauma with facial involvement since obstruction of oral and/or nasal passages is a risk.
Options #1, #3, and #4 are important, but later assessments.

54. Which nursing observation would indicate a serious complication of impetigo?

a. White patches on buccal mucosa.
b. Hearing loss.
c. Respiratory wheezes.
d. Periorbital edema.
Periorbital edema is indicative ofpost-streptococcal glomerulonephritis, a possible complication of impetigo. Option #1
describes a fungal infection. Options #2 and #3 can be caused by many other factors.

55. Which assignment would be most appropriate to assign to the pregnant nurse?
a. A client with HIV.
b. A client with a cervical radium implant.
c. A client with syphilis.
d. A client with cytomegalovirus (CMV).
An HIV client would not present a risk to the pregnant woman if she does not come in contact with the body secretions.
Options #2, #3, and #4 could result in teratogenic effects to the fetus.

56. How should the nurse administer the DPT immunization to a 6-month old?
a. By mouth in three divided doses.
b. As an IM injection into the gluteus maximus.
c. As an injection into the vastus lateralis.
d. As a Z track injection into the deltoid.
Because the muscle mass of an infant is small, the intramuscular injection should be given in the lateral aspect of the thigh
(vastus lateralis). Option #1 is incorrect since the injection is not administered PO. Option #2 is incorrect because the gluteus
does not have enough muscle mass. Option #4 is not necessary, and the deltoid is an incorrect area for this method of
administration.

57. When assisting with a bone marrow aspiration, the nurse would plan to handle supplies by:
a. handling additional supplies by dropping them onto a sterile tray.
b. having all sterile packs unwrapped for the procedure in case needed
c. reaching over the tray to remove contaminated supplies.
d. placing the bottle of sterile liquid on the sterile receptacle to avoid splashing.
Sterile articles are to be dropped at a- reason able distance from the edge of the sterile area. Option #2 is incorrect because
sterile packs should be opened only as needed. Option #3 is incorrect because an unsterile arm should never reach over a
sterile field: Option #4 is incorrect because the outer lip of a bottle containing sterile liquid is not considered sterile.

58. Which action is necessary to maintain asepsis during a sterile dressing change?
a. After scrubbing for the procedure, hold your elbows close to your body.
b. Unused sterile dressing tray can be used for the next client if used within 15 minutes.
c. If you splash a liquid on the sterile field, start over again.
d. If you drop a dressing, leave it until you have completed the procedure.
To maintain a sterile field, all items in that field must remain sterile. Leave the contaminated dressing until the procedure is
completed. Option #1 is incorrect because elbows are held away from the body. Option #2 is incorrect because sterile materials
can be used only for one client; and if unused, must be discarded, or re-sterilized. Option #3 is unnecessary because a liquid
can be covered with a sterile towel.

59. Which statement made by a parent indicates a correct understanding of poison prevention at home?
a. "We store gasoline for the lawn mower in the garage."
b. "All our medications are kept in their original containers."
c. "We keep all our cleaning products in the bathroom."
d. "I keep most of our medications in my purse."
All medications should be kept in their original container and out of reach. Options #1, #3, and #4 are not appropriate safety
measures to prevent accidental poisonings.

60. Which sequence is correct when providing care for a client immediately prior to surgery?
 a. Administer preoperative medication, client signs operative permit, determine vital signs.
b. Check operative permit for signature, advise client to remain in bed, administer preoperative medication.
c. Remove client's dentures, administer preoperative medication, client empties bladder.
d. Verify client has been NPO. Client empties bladder; family leaves room.
The operative permit must be signed prior to the client receiving his preoperative medication. The client is considered
incapacitated after receiving a narcotic. Options #1 and #3 both administer the medication prior to the permit being signed.
Option #4 is important information, but it is unnecessary for the family to leave the room.